Vertigo in a Postpartum Woman with Prior Head and Ear Trauma
Most Likely Diagnosis
Post-traumatic benign paroxysmal positional vertigo (BPPV) is the most likely diagnosis in this 28-year-old woman, given her history of fall with direct ear and jaw trauma. 1, 2
Clinical Context and Pathophysiology
Post-traumatic BPPV develops when head or ear trauma mechanically disrupts the otolithic organs, dislodging calcium carbonate crystals (otoconia) into the semicircular canals. 1 In patients younger than 50 years, trauma is the major identifiable cause of BPPV. 3 The fall from a terrace with impact on the ear and jaw region provides the mechanical force necessary to cause this disruption. 2
Key distinguishing features of post-traumatic BPPV:
- Onset within days to weeks after documented head trauma 2
- More refractory to treatment than idiopathic BPPV, requiring repeated repositioning maneuvers in 67% of cases (versus 14% for idiopathic BPPV) 2
- Higher recurrence rate of 57% (versus 19% for idiopathic BPPV) 2
- May present 5 months post-injury, as vestibular symptoms can persist chronically after trauma 3
Essential Diagnostic Evaluation
Immediate Bedside Testing
Perform the Dix-Hallpike maneuver bilaterally as the gold standard diagnostic test. 4, 5 Look for:
- Latency period of 5–20 seconds before symptoms begin 5
- Torsional, upbeating nystagmus toward the affected ear 5
- Vertigo and nystagmus that increase then resolve within 60 seconds 5
If Dix-Hallpike is negative, perform the supine roll test to evaluate for horizontal canal BPPV. 4, 5
Critical Red Flags Requiring Urgent Neuroimaging
Do NOT assume this is simple BPPV without excluding dangerous central causes. 5, 6 Order MRI brain without contrast immediately if any of the following are present:
- Focal neurological deficits (dysarthria, dysmetria, dysphagia, sensory/motor loss) 7
- Sudden unilateral hearing loss 5
- Inability to stand or walk 5, 6
- Downbeating nystagmus or direction-changing nystagmus without head position changes 5, 7
- New severe headache accompanying dizziness 5
- Failure to respond to canalith repositioning maneuvers 6, 7
Critical pitfall: 75–80% of patients with posterior circulation stroke presenting with acute vestibular syndrome have NO focal neurologic deficits. 5, 7 A normal neurologic exam does not exclude stroke.
When Imaging Is NOT Needed
No imaging is indicated if:
- Positive Dix-Hallpike test consistent with BPPV 5
- Normal neurologic examination 5
- No red flag features listed above 5
- Age < 50 years without vascular risk factors 5
Comprehensive Treatment Algorithm
First-Line Treatment: Canalith Repositioning
Perform the Epley maneuver immediately upon diagnosis. 4, 5 This achieves:
- 80% success rate after 1–3 treatments 4, 5
- 90–98% success rate with repeat maneuvers if initial treatment fails 5
For post-traumatic BPPV specifically, anticipate the need for multiple treatment sessions (67% require repeated maneuvers versus 14% for idiopathic cases). 2
Expected Post-Treatment Course
Patients may experience:
- Immediate symptom resolution in some cases 4
- Continuing motion sickness–type symptoms and mild instability for hours to days 4
- Residual sensitivity to movement for a few days to weeks 4
Follow-Up and Monitoring
Reassess within one month after initial treatment to document resolution or persistence of symptoms. 5 Counsel the patient about:
- High recurrence risk: 57% of post-traumatic BPPV patients experience recurrent attacks (versus 19% for idiopathic BPPV) 2
- Fall risk: Dizziness increases fall risk 12-fold 5, 6
- Return promptly if symptoms recur for repeat repositioning procedures 5
When to Refer for Vestibular Rehabilitation
Refer for vestibular rehabilitation therapy if:
- Symptoms persist despite 2–3 repositioning maneuvers 4, 5
- Patient has concurrent balance impairment or fear of falling 4
- Multiple semicircular canals are involved 5
Vestibular rehabilitation significantly improves gait stability compared to medication alone. 5
Additional Considerations in This Case
Postpartum Context
While the postpartum period (5 months) is not directly causative of BPPV, consider:
- Medication review if patient is taking any vestibular suppressants or antihypertensives 5, 3
- Sleep deprivation and positioning during infant care may exacerbate positional symptoms 4
Associated Symptoms to Assess
Ask specifically about:
- Neck pain (present in 87% of chronic BPPV patients) 3
- Headache (present in 75% of chronic BPPV patients) 3
- Visual disturbances (present in 84% of chronic BPPV patients) 3
- Fatigue (present in 85% of chronic BPPV patients) 3
These symptoms are common in chronic post-traumatic BPPV and do not indicate a central cause if the neurologic exam and Dix-Hallpike are consistent with peripheral BPPV. 3
Jaw Trauma Consideration
The jaw impact raises the possibility of temporomandibular joint (TMJ) dysfunction contributing to cervicogenic dizziness, but this would not cause true rotatory vertigo. 5 If the Dix-Hallpike is negative and symptoms are vague dizziness rather than vertigo, consider TMJ evaluation.
Medications to Avoid
Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV. 4, 8 These medications:
- Do not treat the underlying mechanical problem 4
- Delay central compensation 8
- Are appropriate only for acute symptom relief during severe distress 4
Antiemetics (metoclopramide, prochlorperazine) may be used briefly for severe nausea during the acute phase only. 5
Summary Algorithm
- Perform Dix-Hallpike maneuver bilaterally 5
- If positive: Perform Epley maneuver immediately 5
- If negative or atypical features: Assess for red flags 5, 6
- If red flags present: Order MRI brain without contrast urgently 5
- If no red flags and negative Dix-Hallpike: Consider alternative diagnoses (vestibular migraine, Ménière's disease, vestibular neuritis) 5, 7
- Reassess in one month and counsel about recurrence risk 5, 2
- If symptoms persist after 2–3 repositioning attempts: Refer for vestibular rehabilitation 5